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Med reviews in gp practices2007

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Medication Reviews – where did it all start?� There is considerable published evidence on: � issues associated with medicines � benefits of medication reviews� Paper in Am J Hosp Pharm (1992) – effects of pharmaceutical care on quality of patient care in an ambulatory-care clinic� Many other papers from 1999, 2001, and so on about medication reviews conducted by pharmacists in GP practices (BMJ)� NSF for Older People: all people over 75 yrs to have all meds reviewed annually, and for those taking four or more meds to have a six-monthly medication review (2001)

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Key Features of ‘Room forReview’� Greater patient and carer involvement in medication review as a route to partnership in treatment decisions and medicine taking: � Concordance� Guide focussed on the practice of medication review in primary care with the needs of older people, & people with long term conditions particularly in mind� There are practical issues for the NHS in relation to capacity and staff time to undertake medication review and meet NSF and other targets: � Usingskills of different healthcare professionals – pharmacists

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The need for medication reviewMedication review is an important component of medicines management:� Medication review milestone in the Older People’s NSF� Medication reviews are specifically mentioned in two sections of the GMS contract: � a medication review is recorded in the notes in the preceding 15 months for all patients being prescribed four or more repeat medicines (standard 80%; medicines 5 indicator) � a medication review is recorded in the notes in the preceding 15 months for all patients being prescribed repeat medicines (standard 80%; medicines 9 indicator)� The importance of medication reviews is further highlighted in a number of areas of the GMS contract including, epilepsy, asthma, CHD and hypertension. Over 300 points are achievable by reviewing medication.

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What is a Medication Review?� ‘A structured, critical examination of a patient’s medicines with the objective of reaching an agreement with the patient about treatment, optimising the impact of medicines, minimising the number of medicine-related problems and reducing waste’ Room for Review, Nov 2002

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Suggested principles of amedication review� All patients should have a chance to raise questions and highlight problems about their medicines� Reviews should seek to improve or optimise impact of treatment for an individual patient� The review is undertaken in a systemic way, by a competent person� Any changes resulting from the review are agreed with the patient� The review is documented in the patient’s notes� The impact of any change is monitored

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What patients want from medication reviews� General information about the medical condition & treatment � Confirmation of ‘what medication are on & why’� How to take pills properly � What to take & how much� Medication options � Alternative formulations to aid compliance� Personal beliefs & preferences� Concerns about medication � Adverse drug effects

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Levels of Medication ReviewThis is what we should readcode ‘medication reviewdone’ (‘seen by pharmacist’code can also be added here) This is what we should read code as XaloW – ‘medication review done by pharmacist’

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Level 1 – Prescription ReviewCommunity MURs� Reviews done without access to the patient’s clinical notes and do not often include a review of the full repeat prescription (e.g. go by what the patient or pharmacy PMR says)� Compliance issues, dose & pack optimisation, resolving quantity problems & generic switches can be dealt with at this level� MURs are an integral part of the Pharmacy Contract – each MUR attracts a £25 fee (paid by PCT to the Pharmacy)

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Level 2 – Treatment Review‘Medication review done by pharmacist’� These reviews are done by pharmacists (or GPs) but without the patient� Medicines can be reviewed in the context of the patient’s medical condition, history & treatment� Review relies on formal record rather than patient’s own account of the medicines they take� Dose adjustments, removal of unwanted items, effect of medicines on pathology (e.g. DMARDs & FBC, ACEIs & renal function), adverse effects, reducing likelihood of drug interactions� Optimising medicines use (changing dosage forms for residents with swallowing difficulties), checking compliance, minimising waste by calculating quantity actually required per prescription interval� Identify patients who need a face to face review

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Level 3 – Clinical Medication ReviewFace to face with patient� At this level medicines will be examined in the context of the patient’s condition & the way they live their lives – listening to the patient’s views & beliefs about their medicines, understanding their medicine taking behaviour, & taking full account of their preferences in any decisions about treatment� Objective evidence e.g. BP; peak flow done� A check to ensure the patient understands how to take medications (inc. storage conditions)� Requirements for any additional support (e.g. dosettes, repeat dispensing, collection services by local pharmacy)� The review should conclude with a summary of the agreement with the patient about the treatment & an explanation of what will happen next (e.g. date of next review)

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Recording Medication Reviews� Pharmacists are well recognised as being experts in pharmaceutical knowledge and communication skills� Conducting medication reviews (with or without patients) is an important opportunity for pharmacists to establish the concept of partnership between patients & health professionals in relation to medicines� It is imperative that this valuable support that we provide to our practices gets recorded & fed back to the PCT� We all have a responsibility to record this information on our practice timesheets & emailed to Hab before the end of each week so that data can be recorded

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Medication Reviews in SystmOne� Mostly done when ‘reauthorising’ medication for another 6 months� The read code ‘XaloW’ should be used� Clinical reports can be created for patients on ‘x’ number of medicines which can be used to do medication reviews on patients records when have time after other daily duties

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Reauthorising medication as partof a Medication Review� Before reauthorising medication for another six months, the following sections must be viewed in the patients record: � Quick Glance � Summary & Family History � New Journal � Recent issues & repeat template � Communications � Pathology

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Quick Glance Note the last time BP, BMI & smoking status was checked, check to see if information is present / absence here Check if patient is allergic to any medicationCheck the lastthreeconsultationsin the patientsrecord See if there are any important recalls e.g. diabetes review

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Summary & Family History Check the summary of the patients medical conditions (listed in date order here)Check for anyrelevantfamily history

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New Journal By clicking on the ‘custom’ yellow cup, the new journal window can be maximisedThe highlighted section above isexpanded providing moreinformation such as blood results,letters & prescriptions issued

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Recent issues Check if any important medication has been issued as an acute – some drugs may be being titrated By right clicking on a drug and selecting issue history, aBy changing detailed recordthe option to appears for thatsummary, a list drugof every drugever issuedappears

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Repeat template The date when a medication The date when Issue review due the medication duration was last issued Frequency Date when next of issues supply of Person medication due authorising Clicking on medication this bar will arrange drugs in alphabetical orderThe number ofrepeat medication Date medication Number ofthe patient is on started issues left

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Communications Look through recent letters to see if there has been any change in medication, or medical condition

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Expanding this + sign Pathology gives an option to view trends in the pathologyThis screen gives info on themanagement of the resultsi.e. whether the patientneeds to be informed

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Results in pink are abnormal; green are OK Clicking the BP button brings up a graph with recent BP readingsClicking the data tab willlist all the BP readings withdates ever done

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Read coding� After all the medication have been reauthorised, ensure that each medication has a correct read code assigned to it. If a read code is missing, check the diagnosis box, new journal and communications sections to find the appropriate read code or the date for the diagnosis (which can then be read coded) Diagnosis box� Sometimes may have to look in paper records to find the diagnosis to read code

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Consultation� An entry needs to be made in the consultation� Some practices will have templates where this entry can be made� After the consultation is written, this needs to be read coded ‘medication review done by pharmacist’ or XaloW If a read code is not known by value, free typing the word will bring a browser up

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Putting Medication Review into practice� Select patients via Clinical Reporting (ask Hab to show you)� Discuss with GP which patients need to be seen (complex drug treatments, chronic disease patients, etc)� Develop good working relationships with the local community pharmacists who can check compliance via MURs if time is limited to see patients (e.g. if do surgery half day)